TONGUE updated ultima

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full anatomy and applied

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G ood afternoon Bon l’après-midi நல்ல மதியம் మంచి మధ్యాహ్నం नमस्कार

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TONGUE

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TONGUE - Glossa [Greek] TONGUE - Lingua [Latin] INTRODUCTION

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Location Parts of tongue Muscles Arterial supply Venous drainage Embryological origin Innervations Lymphatics Applied aspects compendium

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Tongue is partly oral and partly pharyngeal in position . Tongue is attached by its muscles to the hyoid bone, styloid process, soft palate and the pharyngeal wall . LOCATION

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The tongue has a- Root Apex Curved dorsum Inferior surface ‘V’ shaped terminal sulcus of tongue. Foramen caecum. Lingual frenulum Vallecular region PARTS

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The dorsum of the tongue is covered by mucosa – soft, pink and moist. The dorsal mucosa consists of numerous LINGUAL PAPILLAE in the anterior 2/3 rd . The dorsum of the tongue contains numerous lymphoid tissue elevations called LINGUAL TONSILS in the posterior 1/3 rd . DORSUM

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Lingual papillae are projections of the mucosa covering the dorsal surface of the tongue There are 4 principal types namely FILIFORM PAPILLAE FUNGIFORM PAPILLAE FOLIATE PAPILLAE CIRCUMVALLATE PAPILLAE LINGUAL MUCOSA

INFERIOR SURFACE :

INFERIOR SURFACE Inferior surface has frenulum linguae On either side of frenulum, deep lingual veins are seen. Still lateral plica fimbriata are present

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Near the base of the tongue – sublingual folds which open through sublingual papillae are seen Submandibular duct opens in sublingual papillae Rivinus ducts open on the surface of sublingual folds

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TONGUE IS DIVIDED BY A MEDIAN FIBROUS SEPTUM ATTACHED TO THE BODY OF HYOID BONE. THERE ARE EXTRINSIC AND INTRINSIC MUSCLES IN EACH HALF. MUSCLES OF THE TONGUE

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THE EXTRINSIC MUSCLES EXTEND OUTSIDE THE TONGUE MOVING IT BODILY. THE EXTRINSIC MUSCULATURE CONSISTS OF 5 PAIRS OF MUSCLES NAMELY GENIOGLOSSUS HYOGLOSSUS CHONDROGLOSSUS STYLOGLOSSUS PALATOGLOSSUS EXTRINSIC MUSCLES

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ORIGIN :SUPERIOR GENIAL TUBERCLE ,SYMPHYSIS MENTI. INSERTION : UPPER AND MIDDLE FIBRES –ROOT TO THE APEX OF TONGUE LOWER FIBRES-BODY OF THE HYOID BONE NERVE SUPPLY :HYPOGLOSSAL NERVE[XII] VASCULAR SUPPLY : SUBLINGUAL BRANCH OF LINGUAL ARTERY AND SUB MENTAL BRANCH OF FACIAL ARTERY ACTION :PROTRUSION OF TONGUE GENIOGLOSSUS GENIOGLOSSUS

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ORIGIN: UPPER SURFACE OF THE GREATER CORNU AND BODY OF THE HYOID BONE INSERTION: LATERAL SURFACE OF TONGUE NERVE SUPPLY :HYPOGLOSSAL NERVE[XII] VASCULAR SUPPLY : SUBLINGUAL BRANCH OF LINGUAL ARTERY AND SUB MENTAL BRANCH OF FACIAL ARTERY ACTION :IT DEPRESSES THE TONGUE HYOGLOSSUS HYOGLOSSUS

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ORIGIN :LESSER CORNU OF HYOID BONE INSERTION: ON THE SIDE OF TONGUE BETWEEN HYOGLOSSUS AND GENIOGLOSSUS NERVE SUPPLY :HYPOGLOSSAL NERVE [XII] VASCULAR SUPPLY: SUBLINGUAL BRANCH OF LINGUAL ARTERY AND SUB MENTAL BRANCH OF FACIAL ARTERY ACTION: DEPRESSION OF TONGUE CHONDROGLOSSUS

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ORIGIN : ANTERO- LATERAL SURFACE OF STYLOID PROCESS AND STYLOMANDIBULAR LIGAMENT INSERTION: LATERL SURFACE OF TONGUE NERVE SUPPLY: HYPOGLOSSAL NERVE [XII] VASCULAR SUPPLY : SUBLINGUAL BRANCH OF LINGUAL ARTERY ACTION: ELEVATES AND RETRACTS THE TONGUE STYLOGLOSSUS STYLOGLOSSUS

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ORIGIN :UNDER SURFACE OF PALATINE APONEUROSIS INSERTION :LATERAL MARGIN OF TONGUE NERVE SUPPLY : CEANIAL PART OF ACCESSORY NERVE VIA VAGUS VIA PHARYNGEAL PLEXUS VASCULAR SUPPLY :ASCENDING PALATINE BRANCH OF FACIAL ARTERY ACTION :ELEVATION OF TONGUE ORIGIN:UNDER SURFACE OF PALATINE APONEUROSIS INSERTION:LATERAL MARGIN OF TONGUE NERVE SUPPLY: CEANIAL PART OF ACCESSORY NERVE VIA VAGUS VIA PHARYNGEAL PLEXUS VASCULAR SUPPLY:ASCENDING PALATOGLOSSUS

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THE INTRINSIC MUSCLES LIE WITHIN THE TONGUE ALTERING ITS SHAPE THE INTRINSIC MUSCLES ARE SUPERIOR LONGITUDINAL INFERIOR LONGITUDINAL TRANSVERSUS VERTICALIS INTRINSIC MUSCLES

Superior longitudinal:

Superior longitudinal ORIGIN : sub-mucosal connective tissue at the back of the tongue and from the median septum of the tongue INSERTION :lingual margin of the tongue INNERVATION : hypoglossal nerve [xii] FUNCTION : shortens tongue; curls apex and sides of tongue

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Superior longitudinal

Inferior longitudinal:

Inferior longitudinal ORIGIN : root of tongue(some fibers from hyoid ) INSERTION : Apex of tongue INNERVATION : hypoglossal nerve[xii] FUNCTIONS : shortens tongue; uncurls apex and turns it downwards.

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Inferior longitudinal

Transversus:

Transversus ORIGIN : median septum of the tongue INSERTION : sub mucosal connective tissue on lateral margins of tongue INNERVATION : hypoglossal nerve [xii] FUNCTION : narrows and elongates tongue

Verticalis :

Verticalis ORIGIN : Sub mucosal connective tissue on lateral margins of tongue. INSERTION : sub mucosal connective tissue on dorsum of tongue INNERVATION : hypoglossal nerve [xii] FUNCTION : flattens and widens tongue.

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Verticalis and transversus VETRICALIS AND TRANSVERSUS

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The tongue and floor of the mouth are supplied chiefly by tortuous lingual artery. It passes between hyoglossus and the middle constrictor of the pharynx to reach the floor of the mouth accompanied by lingual veins and glossopharyngeal nerves. The branches of lingual artery which form a rich anastomotic network and supply the musculature of the tongue are Dorsal lingual arteries and Profunda lingual arteries Arterial supply

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LINGUAL ARTERY

DORSAL LINGUAL ARTERIES:

DORSAL LINGUAL ARTERIES Dorsal lingual arteries arise medial to hyoglossus and ascend to the posterior part of the dorsum of the tongue The vessel supply its mucous membrane, and the palatoglossal arch, tonsil, soft palate and epiglottis.

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The deep lingual artery is the terminal part of the lingual artery It supplies the inferior surface of the tongue DEEP LINGUAL ARTERY

Other arterial supply:

Other arterial supply In addition to the lingual artery other arteries supplying the tongue are Facial artery through Ascending palatine branch Tonsilar branch Ascending pharyngeal branch of external carotid artery

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The veins draining the tongue follow two routes namely, dorsal lingual veins deep lingual veins VENOUS DRAINAGE

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These veins drain the dorsum and sides of the tongue They then join the lingual vein accompanying the lingual artery and drain in the internal jugular vein Dorsal lingual veins

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The deep lingual vein begins near the tip of the tongue and runs back just beneath the mucous membrane on the inferior surface of the tongue. It forms vena comitans nervi hypoglossi and joins facial, internal jugular or lingual vein Deep Lingual Vein

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The development of tongue may be considered under 3 headings: Mucous membrane Muscles Fibro areolar stroma The tongue appears in embryo approximately 4 weeks in the form of 2 lateral swellings and 1 median swelling, the tuberculum impar. From the mesoderm of 2 nd ,3 rd and part of 4 th arch develops a second median swelling called the copula or hypobranchial eminence. EMBRYOLOGICAL ORIGIN

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The lateral lingual swellings increase in size, they overgrow the tuberculum impar and merge forming the anterior 2/3 rd of the tongue. The cranial part of hypobranchial eminence forms posterior 1/3 rd of the tongue. Union of anterior and posterior part corresponds to the angulated sulcus. The nerve supply varies as the arches.

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The muscles of the tongue are derived from the occipital myotomes which invade the mesenchyme of the tongue. The fibro areolar stroma binds the tongue muscles and is derived from the mesenchyme of the pharyngeal arches.

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INNERVATION OF TONGUE IS COMPLEX AND CONSISTS OF THREE DIFFERENT SUPPLIES Motor supply General sensory supply Special sensory supply INNERVATION

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The muscles of the tongue, with exception of palatoglossus, are supplied by the hypoglossal nerve The palatoglossus is supplied by vagus via the pharyngeal plexus Motor supply

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The general sensory sensation is supplied by three nerves Lingual nerve – anterior 2/3 rd of tongue Glossopharyngeal nerve – posterior 1/3 rd o tongue. Vagus nerve – posterior most part of the tongue Sensory supply

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Special sensation is supplied by three nerves Chorda tympani [facial] – taste sensation of the anterior 2/3 rd of tongue. Glossopharyngeal [ix] – taste sensation of the posterior 1/3 rd of tongue. Vagus [x] – taste sensation of the posterior most part of the tongue Special sensory supply

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Lymphatic system of tongue consists of some peculiarities namely Do not accompany the blood vessels Tip of tongue presents richest lymph drainage and drains bilaterally Lymphatic in the posterior 1/3 rd of tongue drains bilaterally Lymphatic of the tongue ultimately drains into jugulo omohyoid nodes, hence they are called lymph nodes of tongue LYMPHATIC DRAINAGE

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LYMPH NODE AFFERENT(RECEIVING) EFFERENT(DRAINING) 1. APICAL i . TIP ii. FRENULUM - SUBMENTAL ( MAJOR LYMPH NODE ) 2. MARGINAL SIDE OF TONGUE IN FRONT OF SULCUS TERMINALIS - SUBMANDIBULAR NODE - JUGULODIGASTRIC - JUGULO OMOHYOID 3. CENTRAL ANTERIOR 2/3 RD LYMPHATIC OF TONGUE IN FRONT OF VALLATE PAPILLAE 4. BASAL POSTERIOR 1/3 RD - BILATERALLY INTO JUGULAR AND DIGASTRIC (MAJOR PART) - JUGULO OMOHYOID LYMPH NODES Lymphatic drainage

APPLIED ASPECTS:

APPLIED ASPECTS TONGUE DISORDERS DEVELOPMENTAL ANAMOLIES IMPORTANT MUSCLE OF TONGUE GAG REFLEX SUBLINGUAL ABSORPTION OF DRUGS

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APHTHOUS ULCERS or STOMATITIS GLOSSITIS CANDIDIASIS FISSURED TONGUE COATED TONGUE GEOGRAPHIC TONGUE CARCINOMA OF TONGUE TONGUE DISORDERS

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60 The tongue is considered a good reflection of general health status of the human body. Tongue disorders could be due to local causes or manifestation of systemic disease.  Alteration in: size, shape, color, moisture, coating, nature of papillae and movements. Some of these disorders can be diagnosed easily by its clinical presentation. Other conditions required further investigation to identify their exact etiology, like:

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61 diabetes mellitus, anemia, gastrointestinal disease, stress, alcoholic, long term antibiotics, nutritional deficiency, tongue movement disorders, and Bell’s palsy. Tongue disorders were more common among males, non smokers, and patients with bad oral hygiene and increased with increasing age. Fissured tongue and geographic tongue were more common than other diseases. Dentist can diagnose systemic diseases from tongue status.

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62 Traumatic ulcer of the tongue. Erosions on the dorsum of the tongue caused by very hot food. 1-Sore tongue: A-Ulcers of any type Tongue disorders

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19/11/2013 63 Redness smoothness, and soreness. Causes: Anaemia (iron deficiency, pernicious anaemia) Vit.B group (B12) deficiencies. Candidosis Acute antibiotic stomatitis Sjogrens syndrome Lichen planus. B- B-Glossitis

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64 Candidiasis

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65 Fissured tongue

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66 Tongue coated with desquamating cells and debris In those who smoke heavily, Gastro intestinal tract problem, Infections, and Childhood fevers especially scarlet fever. Scarlet fever, red and edematous tongue, partially covered by a thick white coating. These conditions are typically asymptomatic, Both conditions may be associated with halitosis. Coated tongue

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67 An irregular smooth red area with a sharply- defined edges, extends for a few days, then heals, only to appear again in another area. Unknown etiology but some times there is a clear family history of its presence in several generations, and In many patients seems to be a developmental anomaly, There also appear to be associated with: Psoriasis, Stress, and Nutritional deficiency. D-Geographic tongue

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Early squamous cell carcinoma of the lateral border of the tongue Carcinoma of tongue

EMBRYOLOGICAL ANAMOLIES:

EMBRYOLOGICAL ANAMOLIES AGLOSSIA MACROGLOSSIA BIFID TONGUE ANKYLOGLOSSIA or TONGUE TIE LINGUAL THYROID

AGLOSSIA:

AGLOSSIA

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71 Macroglossia describes a tongue enlarged out of proportion to the size of the jaw. The pressure of the teeth on the enlarged tongue can produce scalloping along the border and patients may complain of tongue biting. Important causes: A-Congenital ( haemangeoma or lymphangeoma ). B-Downs syndrome C- Critinisim D- Acromegaly E- Amyloidosis F-Lingual thyroid Other causes of macroglosia: hypothyroidism, tongue inflammation, tongue infection, syphilis, amebic dysentery, Ludwig angina, pneumonia, pemphigus vulgaris, rheumatic fever, small pox, typhoid, tuberculosis, actinomycosis, giant cell arteritis, candidiasis, scurvy, pellagra, diabetes, uremia, myxedema, radiation therapy, neoplasm, carcinoma, plasmacytoma, neurofibromatosis, sarcoidosis, tongue trauma. - Macroglossia

BIFID TONGUE:

BIFID TONGUE

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73 Ankyloglossia, commonly known as tongue tie, is a congenital which may decrease mobility of the tongue and is caused by an unusually short, thick lingual frenulum. Ankyloglossia

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74 Raised asymptomatic mass about 2 cm in diameter. Hemorraghe, dysphagia, dysphonia, sympotoms of hypothyroidism can be associated with this condition. It presents as an asymptomatic nodular mass of the posterior lingual midline, usually less than a centimeter in size but sometimes reaching more than 4 cm. in size . Larger lesions can interfere with swallowing and breathing , Up to 70% of patients with lingual thyroid have hypothyroidism and 10% suffer from cretinism. The lingual thyroid is four times more common in females than in males. Lingual thyroid

IMPORTANT MUSCLE OF THE TONGUE:

IMPORTANT MUSCLE OF THE TONGUE GENIOGLOSSUS SAFETY MUSCLE OF THE TONGUE Suffocation if this muscle is injured Air tube should be inserted when anesthesia is given. Used to detect the paralysis of tongue

GAG REFLEX:

GAG REFLEX VOMITING SENSATION WHEN THE POSTERIOR 1/3 RD OF THE TONGUE IS IRRITATED. AFFERENT: GLOSSOPHARYNGEAL NERVE EFFERENT: CRANIAL PART OF ACCESSORY NERVE via VAGUS

SUBLINGUAL ABSORPTION OF DRUGS:

SUBLINGUAL ABSORPTION OF DRUGS Used in case of ANGINA PECTORIS VASO DILATORS are kept beneath the tongue as they are absorbed directly into the DEEP LINGUAL VEINS

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11/19/2013 79 Thank you M erci

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